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Acute Abdominal Pain
Uppsala universitet, Medicinska och farmaceutiska vetenskapsområdet, Medicinska fakulteten, Institutionen för kirurgiska vetenskaper.
2006 (Engelska)Doktorsavhandling, sammanläggning (Övrigt vetenskapligt)
Abstract [en]

The aim was to identify diagnostic difficulties for acute abdominal pain at the emergency department and during hospital stay. A total of 3349 patients admitted to Mora Hospital with acute abdominal pain of up to seven days duration, were registered prospectively for history and clinical signs according to a structured schedule. The preliminary diagnosis from the attending physician at the emergency department, any investigations or surgery and final diagnosis were registered at a follow-up after at least one year.

There were no differences in diagnostic performance between physicians with 0.5 to 5 years of medical experience. The information collected and a careful examination of the patient was more important than formal competence. The main differential diagnostic problem was non-specific abdominal pain; this was the same for diagnoses requiring surgery. Patients originally diagnosed as not needing surgery had a median delay before operation of 22 hours (mean 40 hours, with 95% confidence interval of 30-50 hours), compared to 8 hours (mean 15 hours, 95% confidence interval of 12-28 hours) for patients with the same final follow-up diagnosis as the preliminary diagnosis. Constipation was a diagnostic pitfall, as 9% of the patients considered constipated required surgery for potentially life threatening reasons and 8% were later found to have an abdominal malignancy. Both the preliminary diagnosis and the discharge diagnosis were less reliable for elderly patients than for younger patients. Elderly patients often had specific organ disease and arrived at the emergency department after a longer history of abdominal pain.

This study confirms that assessment of suspected appendicitis can still be based on clinical judgements combined with laboratory tests. Classical clinical findings indicating localised inflammation, such as isolated pain in the right iliac fossa, rebound tenderness, right-sided rectal tenderness, pain migration to the right iliac fossa, local guarding and aggravation of pain when moving, were reliable for predicting acute appendicitis. A CT scan can be saved for the more equivocal cases of acute abdominal pain. A generous strategy regarding CT scan among elderly patients with acute abdominal pain, even in the absence of pronounced signs of an inflammatory intra-abdominal process, is recommended.

Ort, förlag, år, upplaga, sidor
Uppsala: Acta Universitatis Upsaliensis , 2006. , s. 72
Serie
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 174
Nyckelord [en]
Surgery, acute abdominal pain, diagnostic pitfalls, decision-making, competence, sensitivity, specificity, high age, acute appendicitis
Nyckelord [sv]
Kirurgi
Identifikatorer
URN: urn:nbn:se:uu:diva-7161ISBN: 91-554-6664-8 (tryckt)OAI: oai:DiVA.org:uu-7161DiVA, id: diva2:168927
Disputation
2006-10-13, Enghoffsalen, Thoraxcentrum, ingång 50, Akademiska sjukhuset, Uppsala, 13:15
Opponent
Handledare
Tillgänglig från: 2006-09-22 Skapad: 2006-09-22 Senast uppdaterad: 2011-06-10Bibliografiskt granskad
Delarbeten
1. Acute abdominal pain in a defined population: – the impact of the formal competence of the physician and the use of a structured schedule for investigation
Öppna denna publikation i ny flik eller fönster >>Acute abdominal pain in a defined population: – the impact of the formal competence of the physician and the use of a structured schedule for investigation
Artikel i tidskrift (Refereegranskat) Submitted
Identifikatorer
urn:nbn:se:uu:diva-94905 (URN)
Tillgänglig från: 2006-09-22 Skapad: 2006-09-22Bibliografiskt granskad
2. Diagnostic pitfalls and accuracy of diagnosis in acute abdominal pain
Öppna denna publikation i ny flik eller fönster >>Diagnostic pitfalls and accuracy of diagnosis in acute abdominal pain
2006 (Engelska)Ingår i: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 41, nr 10, s. 1126-1131Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Objective. To identify the differential diagnostic difficulties in acute abdominal pain at the emergency department and during hospitalization. Material and methods. Patients with abdominal pain lasting for up to 7 days were registered during 1997-2000 and re-evaluated one year after discharge (n=2851). Results. Diagnoses with low sensitivity at the emergency department but markedly increased sensitivity at discharge were non-specific abdominal pain with a sensitivity value at the emergency department of 0.43, appendicitis 0.80, gallstones 0.68, constipation 0.74 and peptic ulcer 0.26. Corresponding K-values were 0.48, 0.74, 0.84, 0.88 and 0.93, respectively. Malignancy, gynaecological complaints, dyspepsia, urinary tract infection and diverticulitis displayed fairly good concordance between the preliminary and discharge judgements, but the predictive diagnostic value was still low at discharge. Sensitivity values at discharge were 0.40, 0.75, 0.73, 0.77 and 0.83, respectively. Among 479 surgically treated patients, 104 initially received a diagnosis usually not requiring surgery and had a median delay until operation of 22 h (95% CI 30-50 h), compared with 8 h (12-18 h) for referrals. Conclusions. Non-specific abdominal pain is the main differential diagnostic problem in the emergency department also for diagnoses requiring surgery. Constipation is a diagnostic pitfall and when making this diagnosis a careful re-evaluation is necessary.

Nyckelord
acute abdominal pain, decision-making, diagnosis, sensitivity, specificity, validity
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:uu:diva-94906 (URN)10.1080/00365520600587485 (DOI)000240662200002 ()16990196 (PubMedID)
Tillgänglig från: 2006-09-22 Skapad: 2006-09-22 Senast uppdaterad: 2017-12-14Bibliografiskt granskad
3. Acute abdominal pain among elderly patients
Öppna denna publikation i ny flik eller fönster >>Acute abdominal pain among elderly patients
2006 (Engelska)Ingår i: Gerontology, ISSN 0304-324X, E-ISSN 1423-0003, Vol. 52, nr 6, s. 339-344Artikel i tidskrift (Refereegranskat) Published
Abstract [en]

Background: Diagnosis of acute abdominal pain in older persons is a challenge, with the age-related increase in concurrent diseases. In most western countries the number of elderly people is constantly rising, which means that an increasing proportion of patients admitted for abdominal pain at the emergency department are elderly. Objective: To characterize differences in clinical presentation and diagnostic accuracy between younger and more elderly patients with acute abdominal pain. Methods: Patients admitted to Mora Hospital with abdominal pain of up to seven days' duration were registered according to a detailed schedule. From 1st February 1997 to 1st June 2000, 557 patients aged 65-79 years and 274 patients aged ≥80 years were registered. Patients aged 20-64 years (n = 1,458) served as a control group. Results: A specific diagnosis, i.e. other than 'non-specific abdominal pain', was established in 76 and 78% of the patients aged 65-79 and ≥80 years respectively, and in 64% of those aged 20-64 (p < 0.001). Pain duration before admission increased with age (p < 0.003), as did frequency and duration of hospitalization (p < 0.0001). Hospital stay increased from 170 days per 100 emergency admissions in the control group to 320 and 458 days in the younger and older study groups, respectively. At the emergency department, older patients were more often misdiagnosed than control patients (52 vs. 45%; p = 0.002). At discharge the diagnosis was more accurate in the control group (86 vs. 77%; p < 0.0001). Hospital mortality was higher among older patients (23/831 vs. 2/1,458; p < 0.001). The admission-to-surgery interval was increased (1.8 vs. 0.9 days, p < 0.0001) in patients ≥65 years. Rebound tenderness (p < 0.0001), local rigidity (p = 0.003) and rectal tenderness (p = 0.004) were less common in the older than in the control patients with peritonitis. In patients ≥65 years, C-reactive protein did not differ between patients operated on and those not, contrary to the finding in patients <65 years (p<0.0001). Conclusion: Both the preliminary diagnosis at the emergency department and the discharge diagnosis were less reliable in elderly than in younger patients. Elderly patients more often had specific organic disease and arrived at the emergency department after a longer history of abdominal pain compared to younger patients.

Nyckelord
Acute abdominal pain, Decision making, Diagnosis, Morbidity, Mortality
Nationell ämneskategori
Medicin och hälsovetenskap
Identifikatorer
urn:nbn:se:uu:diva-94907 (URN)10.1159/000094982 (DOI)000241816800002 ()16905885 (PubMedID)
Tillgänglig från: 2006-09-22 Skapad: 2006-09-22 Senast uppdaterad: 2017-12-14Bibliografiskt granskad
4. Manifestations of acute appendicitis: – a prospective study on acute abdominal pain
Öppna denna publikation i ny flik eller fönster >>Manifestations of acute appendicitis: – a prospective study on acute abdominal pain
Manuskript (Övrigt vetenskapligt)
Identifikatorer
urn:nbn:se:uu:diva-94908 (URN)
Tillgänglig från: 2006-09-22 Skapad: 2006-09-22 Senast uppdaterad: 2010-01-13Bibliografiskt granskad

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